Pharmaceutical Education

Social Pharmacy as a Field of Study in Undergraduate Pharmacy Education

Jan Kostriba, M.S.a,*, Abdullah Alwarafi, Ph.D.b and Prof. Jiri Vlceka

aFaculty of Pharmacy in Hradec Kralove, in Prague, Czech Republic bFaculty of Dentistry, Ibb University, Yemen

Submission Date: 8-10-2013; Review completed: 20-12-2013; Accepted Date: 21-1-2014

ABSTRACT Objective: To ascertain and compare the differences, extent and depth of education in Social Pharmacy and reveal international regional variations. To analyze Social Pharmacy education at different pharmaceutical faculties. To examine the range and scope of teaching subjects partially related to the social, behavioral and administrative pharmacy sciences. Methods: A questionnaire survey was developed based on the examination of the study plans of 15 pharmacy schools around the world. A questionnaire was created based on the analysis of the curricula and mailed to 371 deans (or heads of Departments of Social Pharmacy) at colleges and schools of pharmacy in Europe, North America and developing countries (Latin America, Asia and Africa). Results: Fifty-one usable surveys were returned to the authors (a 53% response rate). 41% of the respondents reported that their school of pharmacy had a Social Pharmacy Department. In addition, 41% of the schools featured Social Pharmacy as a separate subject. This article describes regional differences and different representation of sub-disciplines. Conclusions: Although the most of surveyed schools had Social Pharmacy and related sub-disciplines in their curricula, there were large differences in approach and scope of teaching. Regional trends were discovered connected with the economic, political and social environment of particular regions. Keywords: Social Pharmacy, curriculum, undergraduate, pharmacy education.

INTRODUCTION lines, different curriculum studies have recently been conducted.1,2 DOI: 10.5530/ijper.48.1.2 Many changes regarding how health care and its role in society is viewed, as well as The role of the has been Address for correspondence how the role of the pharmacist is perceived described as having eight functions: care- Jan Kostriba, M.S. in particular regions. Creating policy with giver, decision-maker, communicator, man- Department of Social and the goal of increasing the safety, quality and ager, life-long learner, teacher, leader, and Clinical Pharmacy Faculty of 3,4 Pharmacy in Hradec Kralove effectiveness of medicines has required researcher. Within this context, there is a Charles University in Prague the development of study programs such need for future to be trained Ak. Heyrovskeho 1203 in all aspects related to Social Pharmacy, as Hradec Kralove 500 05 as Social Pharmacy as well as associated Tel.: +420 495 067 271 subjects. The rapidly developing need for this provides the background for provid- Email: such programs as Social Pharmacy can be ing the patient-oriented services associated [email protected] 5 mirrored in the emergence of dissimilar with each function. sets of guidelines regarding how to teach To achieve this goal pharmacy educators these subjects. It is therefore necessary to must develop a multi-professional edition of study how these needs have in fact been the Curriculum Guide, a text which can then responded to in university departments. be used to inform, support and assist health With regard to addressing this need for an care professionals, ensuring that patient safety overview of developing trends along these is a top priority in health care education.6 www.ijper.org

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Social Pharmacy is an interdisciplinary discipline which The knowledge gained by the study of Social Pharmacy enables the pharmacy professionals to participate in should be considered essential in synthesizing the asso- and take responsibility for decisions regarding drug- rted bodies of knowledge taught in pharmacy, including related issues at the societal level. The rapidly devel- subjects such as (1) the traditional fundamental sciences oping discipline of Social Pharmacy is likely to have such as chemistry, pharmacology, physiology, law and a central position in the future curricula of pharmacy legislation, (2) clinical subjects such as clinical pharmacy, schools.7 and (3) social science subjects such as communication 10 Social Pharmacy may be defined as the discipline deal- skills. The main objective of our work is to identify ing with the role of medicines from social, scientific subjects in study plans of schools of pharmacy which and humanistic perspectives. It draws on theories of can be connected with social pharmacy in a broad scope. the social and behavioral sciences, including health The second step is a comparison of the representation psychology. Social Pharmacy may be seen as con- of these subjects by region. sisting of all social factors influencing the use of a particular drug, such as medicine-related beliefs, regu- MATERIAL AND METHODS lations, policy, attitudes, medicine information, ethics The first step in the development of our investig- and behavior. Several approaches, however, towards ation questionnaire was an examination of the study a definition of Social Pharmacy have emerged from plans of 15 pharmacy schools around the world. The numerous authors and researchers. In what has subjects taught at these institutions were divided into 4 become a widely accepted definition, one group of different categories: basic, medical, pharmaceutical and authors terms Social Pharmacy as “The endeavor social pharmacy courses.13 Subjects in the social pharmacy to integrate drugs into a broader perspective and to group (specifically Social/Behavioral/Administrative and include legal, ethical, economic, political, social, com- Clinical Pharmacy Sciences) were divided into 14 main municative, and psychological aspects into their evalu- branches – Communication, Education and Research ation in order to contribute to the safe and rational Methods, Ethics, Health and Drug Policy, Industrial use of drugs.”8 Pharmacy, Patient Safety, Pharmaceutical Care, Pharma- There is no single, superlative model for the education coeconomics, Pharmacoepidemiology, Pharmacy Leg- and training of pharmacists which has been accepted islation, Law and Regulations, Pharmacy Management, world-wide, but there are common concepts, principles Pharmacy Practice, Psychology, Social Pharmacy. and practices that should be employed by pharmacy The next phase was the actual creation of a question- education policy-makers to meet the needs of commu- naire based on the results from the first step. The nities at the local, regional and even global level. Toward survey had three parts: the first contained 5 general this end, schools and faculties of pharmacy should questions to obtain descriptive information related share knowledge and educational resources with their to the apposite university/faculty, i.e. name and posi- colleagues world-wide.9 tion of contact person (respondent) and his/her email Social Pharmacy courses in pharmacy curricula are address. Other questions dealt with the number of becoming more important because of the various fac- departments at the respondent’s faculty. The respon- tors that can influence the health of a society. A deep dents were also asked if their faculty had a Social understanding of the issues related to Social Pharmacy Pharmacy department or a similar institution under will help the profession further progress toward improv- a different name and, if so, how many lecturers this 10 ing population health. department had. It can be difficult for somebody to Social Pharmacy deals with the study of human behav- understand exactly what Social Pharmacy is and what ior and as a behavioral science is often associated with it entails, thus a definition was included: “Social phar- disciplines that deal with individuals as well as large macy deals with the role of medicines from the social, and small groups, including psychology, sociology and scientific and humanistic perspectives. It draws on anthropology.11 As a relatively new discipline, the theo- theories of the social and behavioural sciences, and retical bases of research in the area of Social Pharmacy includes health psychology.”14 12 are still in the process of development. The second part of the questionnaire dealt with ques- The objective of our study was to compare the repre- tions regarding 14 selected courses and subjects. sentation of individual disciplines in a wide range of Respondents answered as to if a particular subject was institutions around the world dealing with aspects of offered in their curriculum, if the content of the field Social Pharmacy. Our aim is to describe significant of knowledge was taught in another course, or if this regional differences and identify deficiencies in the con- issue was not included in the curriculum at all. The sec- tent of particular study programs. ond question in this part of questionnaire was about Indian Journal of Pharmaceutical Education and Research | Vol 48 | Issue 1 | Jan–Mar, 2014 7 Jan Kostriba, et al.: Social Pharmacy as a Field of Study in Undergraduate Pharmacy Education whether the said course was obligatory (compulsory) in type of health care systems, economic status18 and or elective (optional). The third question concerned the role of pharmacists, regions were divided into three how many hours in total the subject was featured in groups: Europe (4 responses from the United Kingdom, the curriculum. 3 from Portugal, 2 each from the Czech Republic and The third part of the questionnaire was devoted to all Sweden, and 1 each from Denmark, Estonia, Finland, other subjects related to Social Pharmacy and there was Germany, Macedonia, Malta, Netherlands and Slova- space for additional comments, suggestions and expla- kia), North America (15 responses from the USA and nations. 1 from Canada) and developing countries - Latin America (1 response each from Argentina, Colombia, Chile The completed questionnaire was modified into and Peru), Asia (2 each from Saudi Arabia and United electronic form and an online version was mailed Arab Emirates, and 1 each from Indonesia, Iran, Leba- to 371 deans (or heads of Departments of Social non, Malaysia, Nepal, Palestine and Yemen), Africa (1 Pharmacy or other individuals responsible for the response from Egypt). Table 1 shows the number of teaching of Social Pharmacy) at colleges and schools countries surveyed as well as the number of responses of pharmacy in Europe, North and Latin America, and response rate. Asia, Africa and Australia. The free online service Google Docs was used to create the questionnaire.15 Regional differences were significant as to the num- The list of pharmacy schools, the names and email ber of relevant departments in the schools. While the addresses of the deans as well as information regard- European median value was five departments, in North ing the web pages of colleges and the names of America there were only two, and for developing coun- heads of departments of Social Pharmacy or associ- tries the median value was four departments. ated instructions was taken from the International About two-fifths of the respondents (41%) reported Pharmaceutical Federation16 and the Accreditation that their school of pharmacy has a Social Pharmacy Council for Pharmacy Education.17 The link to the department or a department with a similar name deal- online questionnaire was sent by email in a cover let- ing with similar issues. Table 2 shows these regional ter in email form describing the intentions and aims differences. of the study and thanked participants in advance Social Pharmacy can be managed either as a module of for their cooperation in the survey. To maximize the individual courses/topics within one department, or response rate, the cover letter was sent again after other institution dealing directly with this research or as 4 weeks to another contact at the schools that had not a set of courses within various subdivisions (e.g. depart- responded to the first attempt. Considering the type ments) working independently of each other (all individ- of survey and work with publicly accessible data no ual courses related to Social Pharmacy then harmonized informed consents or ethical approvals is required. into one module). 41% of the schools included Social The data collection lasted two months (October and Pharmacy as one separate course only, more often in November 2012) and the results were processed by Europe (59%), and less so in North America (25%) and ® MS Excel . developing countries (38%). The main scope of our survey was focused on Social RESULTS Pharmacy subdisciplines. A number of disciplines such The study involved 51 faculties; the response rate was a as Pharmacy Legislation, Law and Regulations, Phar- total of 53%. Based on relevant statistics and similarity macy Practice, and Ethics and Pharmaceutical Care were

Table 1: Response Rate by Region, N=378 Region No. of Schoolsa No. of Surveyedb No. of Responses (Response Rate)c Europe 111 32 19 (59%) North America 125 36 16 (44%) Latin America 48 9 4 (44%) Asia 80 13 11 (85%) Africa 5 3 1 (33%) Australia 9 3 0 (0%) Total 378 96 51 (53%) a Number of Pharmacy Schools with email contact found b Number of Pharmacy Schools with deliverable email (active delivery and read receipt confirmations) c Response Rate as the proportion of number of responses to the number of surveyed

8 Indian Journal of Pharmaceutical Education and Research | Vol 48 | Issue 1 | Jan–Mar, 2014 Jan Kostriba, et al.: Social Pharmacy as a Field of Study in Undergraduate Pharmacy Education featured in the curricula of most schools of pharmacy, Third, Health and Drug Policy, Patient Safety: a lack of but there are many regional differences: these types of subjects was shown in the developing First, Pharmacy Management: there is a relative lack of countries group, wherein 38% and 31% of the schools Pharmacy Management courses in European schools, tested did not offer courses in Health and Drug Policy with 26% not featuring these subjects at all, as opposed and Patient Safety, respectively. A detailed representa- to only 6% of the tested institutions in North Amer- tion of this disparity is shown in Table 3 and Chart 1. ica and in developing countries. A similar result was Further results deal with the obligatory or elective char- obtained for the question about Education and Research acter of courses. Differences were shown both region- Methods. This subject is significantly offered less often ally and regarding individual subjects. In Europe and in European schools (not featured in 47% of them). developing countries 83% of all courses related to Second, Industrial Pharmacy and Pharmacoepidemiol- Social Pharmacy were shown to be obligatory, while in ogy: there is a noticeable lack of these types of courses the North American schools tested the rate was 96% in North American schools. Industrial Pharmacy sub- of these subjects being required. A significant number jects are not offered at almost half (44%) of the schools (more then 30%) of some elective courses were not tested in North America, while in Europe and the devel- offered at all in the North American group. These sub- oping world they are featured significantly more often. jects include, in European schools Industrial Pharmacy A similar result was achieved regarding courses in Phar- (50% not offered), Pharmaceutical management (36%) macoepidemiology in two groups - 25% of the schools and Psychology (33%), and at institutions in developing tested in North America and in developing countries countries Pharmacoepidemiology (42% not offered), did not offer Pharmacoepidemiology, while only 5% of Psychology (42%) and Pharmacoeconomics (33%). the European schools surveyed did not feature any of The open question part of questionnaire enabled the these types of subjects at all. respondents to submit information about the other

Table 2: The Presence of the Social Pharmacy Department or Similar, N=51 Region Europe North America Developing Countries Yes 10 52,6% 6 37,5% 5 31,25% No 8 42,1% 10 62,5% 11 68,75% No answer 1 5,3% 0 0% 0 0% Total 19 100% 16 100% 16 100%

Table 3: Absence of Individual Subjects, N=51 Subject Europe (N=19) North America (N=16) Developing Countries (N=16) Communication 16% 6% 6% Education and Research Methods 47% 38% 19% Ethics 5% 6% 6% Health and Drug Policy 16%a 6%b 38% Industrial Pharmacy 21%a 44% 6% Patient Safety 21% 6% 31% Pharmaceutical Care 11% 0%a 0% Pharmacoeconomics 5% 6% 25% Pharmacoepidemiology 5%a 25% 25% Pharmaceutical Legislation, Law and 0% 0% 6% Regulations Pharmacy Management 26% 6% 6% Pharmacy Practice 11% 6%a 0% Psychology 68% 50% 25% Social Pharmacy 16%a 13% 25% a Number of respondents with "no answer" = 1 b Number of respondents with "no answer" = 3

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Chart 1: Absence of Individual Subjects

70%

60%

50%

40%

30% 20% Europe

10% North America Asia, Latin America, Africa 0% Ethics Psychology Patient Safety Communication Social Pharmacy Pharmacy Practice Education and Education Industrial Pharmacy Industrial Pharmaceutical Care Pharmacoeconomics Law and Regulations and Law Pharmacy Legislation, Health and Drug Policy Drug and Health Operations of Research Pharmacy Management Pharmacoepidemiology

Chart 1: Absence of Individual Subjects. courses connected with Social Pharmacy taught at large variations in these factors can be explained by their schools. Subjects dealing with Hospital Pharmacy the great diversity between study plans and educational were reported four times, with the History of Phar- systems and, indeed, in the basic approach to Social macy three times, with Public Health three times, and Pharmacy around the world. Potential changes toward with Health Outcomes twice. Several other types of restructuring are related not only to historical ques- courses were indicated once each: Community Prac- tions (some remaining to be answered19) but question tice, Community Pharmacy, Professional Responsibil- for many other future transformation steps in educa- ity and Leadership, Biomedical Literature Evaluation, tion of pharmacy. Many schools around the world has Drug Literature Evaluation, Patient Assessment, Inter- proved the changes in recent history.20–22 A similar effort viewing Skills, Patient Counseling, Patient Education, toward increased education in Social Pharmacy is evi- Learning Services for Pharmacists, Demography, dent in both developed and developing countries.23–25 Health and Property, Social Determinants and Primary The respondents in our survey admitted the importance Health Care, Drug Consumption, Patient Perspectives, of Social Pharmacy and confirm changes in their cur- Cultural Competency, Quality in Healthcare, Health riculum in the near future in this field. Economics, Health Promotion, Health Sociology and, The role of pharmacists in modern health care is vital, finally, Drugs and Society. and their responsibility in today’s world is increasingly The final section of our survey provided a place for linked to the problem of Social Pharmacy. In addition, additional notes and comments from the respondents, recent developments in pharmacy practice – specifically, who were able to give information about specific aspects from focusing solely on pharmaceutical and medicinal of their curriculum and education systems that were not products to being patient focused - has resulted in an covered in the earlier sections. These included informa- increased interest in Social Pharmacy.26 With this shift, tion about postgraduate lifelong education outside the pharmacists are now taking responsibility for patient university. Some schools also admitted the awareness of medication outcomes and have become more active their lack of Social Pharmacy courses, as well as revealed members of the health care team.3,4 plans about deepening and improving their syllabi and Social Pharmacy as a multidisciplinary subject involves study plans to concentrate more in this area. many activities and it is necessary (not only with research projects) to both think in terms of a wider perspective as well as concentrate on sub-disciplines. For this purpose DISCUSSION we have analyzed curricula from 15 schools to define We found that study plans among the schools tested the most common subjects taught, with a final result of varied greatly. Differences were indicated not only in 14 courses being identified. Other results of our survey, the amount and variety of subjects in Social Pharmacy- e.g. questions about other courses connected with Social related areas, but also in the overall approach to Social Pharmacy taught at a particular school, confirmed the Pharmacy as an essential educational and scientific dis- presence in some measure of all main subjects listed in cipline. These variations between institutions reflect our questionnaire. individual sociological, economical, political, historical The analysis of the presence or absence of specific influences, as well as other types of differences. The subject matter in curricula proved problematic. Some

10 Indian Journal of Pharmaceutical Education and Research | Vol 48 | Issue 1 | Jan–Mar, 2014 Jan Kostriba, et al.: Social Pharmacy as a Field of Study in Undergraduate Pharmacy Education disciplines were taught individually in some schools, at education reflects a movement from a focus primarily others together with different subjects. After analyz- on products towards a greater focus on patients, it can ing all results we decided that the clearest solution was be said that pharmacy education in developed countries to catalog only the absence of a particular discipline remains at an earlier stage in terms of this tendency at the schools, as this provides evidence of a definite (see e.g. the results for industrial pharmacy).27 lack which may be most straightforwardly addressed. Also the exact number of hours each subject is taught LIMITATIONS was very difficult to infer. The first problem was how compare one-term and two-term (and longer) subjects, This study had several limitations. First, the database of subjects taught during an entire term, subjects taught in email addresses available did not include contacts for all blocks and, of course, the previous discussed problem pharmacy schools. The study included only schools that of isolated nature of some subjects, as in many cases have a functional website and email addresses. Number these were part of other courses or represented only of pharmacy schools with deliverable email (active deliv- by few hours of instruction. Some questions sought to ery and read receipt confirmations) was only 96, becase clarify specifics about the type of teaching, i.e. whether others (from 378 found contacts) had wrong or incor- it took place in divided lectures, seminars or practical rect e-mail contact on their web sites. This presented exercises. Due to the great diversity as well as inaccuracy a big problem in terms of contacting most schools in of some of the answers in this part of questionnaire, it some developing countries (mainly in Africa and Asia) was not possible for us to carry out statistical process- without a quality Internet connection. Second, language ing and evaluation. The problems regarding the overall barriers proved problematic, as those who cannot speak analysis also arose from differences in educational sys- English were undoubtedly discouraged from complet- tems, bachelors’ vs. masters’ programs and the actual ing the questionnaire. Third, the number of respondents requirements therein along with the definition and (response rate) could have been higher, but 53% for this content of the subjects. These problems proved ubiq- type of study was enough, enabling us to at least begin to uitous throughout our survey in terms of comparisons understand the basic features of the issue. Fourth, many between larger regions. respondents did not understand the exact meaning of the questions, and thus their responses could have been On the other hand, the fact that many similarities were imprecise. This seemed to pose a problem with the ques- found among schools within the same region simplified tions dealing with the number of hours some subjects the process of comparison. According to the United are taught: some during more then one term, often in Nations classification, developed countries include study blocks or during (or interconnected) with practice those in Europe, North America, Japan, Australia and in pharmacy. Fifth, the determination of exact bound- New Zealand. Other countries are categorized as devel- aries among subjects and syllabi was very difficult and oping.18 This distinction was made not only according this proved problematic in making comparisons. Finally, to the United Nations’ definitions;18 these groupings the fact that no curricula was listed on the websites of proved statistically significant in terms of similarity of most faculties did not allow for a completely reliable the results from the various regions. Another advan- assessment. tage regarding the analysis and comparison of our sta- tistics was also the similar number of respondents in these three groups (19 from Europe, 16 from North ACKNOWLEDGEMENTS America and 16 from developing countries). Although This study was supported by research grant No SVV 267 a representative sample was not determined, a num- 005 from Charles University in Prague, Czech Republic. ber of common regional features were observed, and this was also connected with certain social and politi- cal characteristics. Social Pharmacy-related courses REFERENCES were generally found to be neglected more often in the 1. Kelly A. The curriculum: theory and practice. 5th ed. 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